Basal ganglia cryptococcomas presenting as parkinsonism in an immunocompetent patient

Cryptococcal disease typically presents as meningitis in immunocompromised hosts, whereas basal ganglia cryptococcomas causing parkinsonism in immunocompetent patients are uncommon and easily overlooked. We describe a 61-year-old apparently immunocompetent man with subacute meningoencephalitis, abnormal cerebrospinal fluid (CSF), and a pulmonary nodule initially managed as tuberculous meningitis, who subsequently developed severe asymmetric parkinsonism. Neuroimaging later demonstrated diffuse leptomeningeal enhancement and multiple basal ganglia and brainstem cryptococcomas and repeat CSF and lung biopsy confirmed cryptococcosis. Opening CSF pressure was elevated (24 cm H2O). Induction therapy consisted of liposomal amphotericin B (4 mg/kg/day) for two weeks, followed by high-dose fluconazole consolidation; flucytosine was not available in our institution. Despite guideline-oriented antifungal therapy and a levodopa trial, parkinsonism persisted, suggesting possible structural nigrostriatal injury; however, long-term follow-up and functional imaging were not available to confirm irreversibility. Serial CSF findings summarized (Table 1) highlight the importance of repeated lumbar punctures and targeted mycological testing in subacute meningitis with nondiagnostic initial studies. To contextualize this presentation, we reviewed previously reported cases of cryptococcal parkinsonism (Table 2), which delineate a spectrum from fully reversible to L-dopa-responsive or permanently disabling syndromes, largely determined by the extent and localization of basal ganglia involvement and timeliness of treatment. This integrated case and literature review emphasizes that cryptococcosis should be systematically considered in atypical or rapidly progressive parkinsonism with inflammatory CSF and basal ganglia lesions, even in apparently immunocompetent hosts, and underscores the need for early recognition, comprehensive evaluation of pulmonary and CNS disease, and prolonged antifungal therapy to prevent irreversible neurological sequelae.